Partnership for Health
April - June 2008

Health in Pakistan

Pakistan's high maternal and infant mortality rates reflect the country's shortage of trained health workers and its inadequate health infrastructure in underserved districts throughout the country. Poor-quality water and sanitation and insufficient family planning resources exacerbate these problems in many regions. Moreover, alarming levels of infectious diseases, including tuberculosis, pose a threat that extends beyond Pakistan's borders.

Since USAID's $168.9 million Health Program began in Pakistan in 2003, activities have focused on improving maternal and newborn health services, enhancing the accessibility and availability of family planning products, preventing the spread of major infectious diseases, and increasing access to safe drinking water. The program works in underserved districts in all four provinces, Azad Jammu and Kashmir (AJK) and the Federally Administered Tribal Areas (FATA).

Improving Maternal Health

An estimated 350 to 550 Pakistani women die for every 100,000 live births. Currently, more than 65 percent of women in Pakistan deliver their babies at home, and only eight percent of these home births are supervised by a trained attendant. Deaths among newborns, infants and children have not decreased in the past 10 years.

USAID's five-year Pakistan Initiative for Mothers and Newborns (PAIMAN) program is working in 11 districts, two FATA agencies and two frontier regions to reduce the newborn mortality rate and to improve the health of mothers by improving access to quality health care for pregnant women and their infants.

Only 36 percent of Pakistani mothers currently deliver their babies with the assistance of a skilled birth attendant. PAIMAN builds a new cadre of health workers (community midwives) and improves health infrastructure. PAIMAN has enrolled 1,225 women from rural villages in an 18-month skills-based course. These young women will return to their villages to provide pregnancy care and conduct safe deliveries for years to come. The Government of Pakistan (GoP) will train an additional 10,000 community midwives across the country.

PAIMAN has informed more than 1.8 million community members about pregnancy-related dangers. As a result, many remote villages in PAIMAN's focus districts have been mobilized to plan emergency transport arrangements to take pregnant women to hospitals when bleeding or obstructed labor occurs.

Additionally, PAIMAN is renovating and equipping 40 hospitals and rural health centers. Of these, 31 facilities now provide around-the-clock care from 1,405 PAIMAN-trained doctors and Lady Health Visitors capable of handling pregnancy and newborn emergencies.

PAIMAN also trains doctors who work at private clinics located in communities, and the mainstay of Pakistani village maternity care, Traditional Birth Attendants (TBAs). To date, 610 private clinic doctors have completed PAIMAN's courses, and 1,810 TBAs have learned to conduct clean deliveries and to recognize emergencies that require hospital referral. PAIMAN benefits more than 2.8 million married couples and 420,000 newborns.

Improving Child Survival, Health and Nutrition

In the FATA, an estimated 135 out of every 1,000 children under the age of five die, often from treatable ailments. On average, 100,000 children younger than five years old suffer either diarrhea or acute respiratory infections each year.

USAID's three-year Improved Child Health in FATA program is delivering a health package for children under the age of five, covering inoculation, prevention and treatment of respiratory infections and diarrhea, and newborn care and nutrition services. Over the next three years, the program will reach more than 1.61 million adults and more than 246,000 young children in FATA.

Through the program, USAID trains health care providers, improves community knowledge and attitudes towards child health and helps improve access to quality health services across all seven agencies.

The program moves prevention and care services for children out to the community through "child health days," which are events designed to build long-term links between community members and their local health facilities.

Through 697 child health days, the project provided 131,068 children (63,931 boys and 67,137 girls) with medical care, vaccinations and nutritional support. The numbers of children that benefited from specific services were 72,864 treated for acute respiratory infection (ARI), 9,437 for diarrheal diseases, 7,864 for malnutrition, 11,000 provided essential newborn care (ENC), and 29,903 vaccinated against diseases.

The program also strengthens agency headquarters hospitals, local health facilities, and agency health management teams that are working to achieve visible improvements. To date, 522 health providers have received training in newborn and child health care and are now better prepared to deliver high-quality health services. In addition, 174 agency-based Lady Health Workers (LHWs) have received training for better identification of child health illnesses at the community level. Community members have learned to convey messages regarding child health and its importance in 143 sensitization meetings.

At seven tertiary care hospitals, the project has established staff learning centers and has improved medical stores, including child play areas in the hospital compounds. Improvements to child and infant wards along with upgrading of first-level care facilities (700) are in progress.

Providing Information to Make Public Health Choices

Countries must have accurate data for developing effective policies and programs to meet the health needs of their people.

To provide Pakistan with vital information on its population, child and maternal health, and infectious disease status, USAID supports the Pakistan Demographic and Health Survey (PDHS).

The 2006-2007 PDHS is one of the largest household-based surveys ever conducted in Pakistan - collecting information from 102,900 households on the health of women and children in Pakistan. The results of this round of the PDHS will mark the first time in the history of Pakistan that the maternal mortality ratio will be determined through a survey. Previous estimates have been based on indirect methods and techniques.

The final report's national launch in June 2008 will provide reliable figures for Pakistan's maternal mortality ratio, as well as data on the direct and indirect causes of maternal and child deaths, family planning and other vital health issues. Preliminary findings have shown that deaths of infants and children have scarcely decreased in the past 15 years. The PDHS also reports that only 47.3 percent of children are completely immunized.

Supporting Reproductive Health and Birth Spacing

Pakistan has a total fertility rate of 4.1 children born per woman, one of the highest in South Asia. Many couples are unable to adequately provide for the health and education of additional children, but they lack access to modern family planning methods. Meanwhile, the contraceptive prevalence rate has stagnated at around 30 percent for the past several years.

USAID's new Family Advancement for Life and Health (FALAH) supports reproductive health and birth spacing for Pakistani couples, a step that greatly improves survival rates for both mothers and infants. Working with community workers and health care professionals in urban and select rural areas, USAID helps couples gain access to information on reproductive health and modern family planning methods.

FALAH increases the availability of information and family planning services for low-income Pakistani women and operates in all four provinces of Pakistan, particularly in the rural areas of 20 districts. A nationwide contraceptive social marketing program is also a component of the project.

The project promotes birth spacing as an essential health intervention to reduce maternal and child mortality. It also increases the use of contraceptive methods among families that want to space their births. To remove barriers to contraceptive method use, the project works to increase community understanding of the value of birth spacing for family health and well-being. FALAH also improves access to quality care in both the public and private sectors. To date, FALAH has trained 63 women health care providers; has identified 263 private sector service delivery points for family planning counseling and services and certified the quality of services; trained 24 health and population managers on leadership skills. Importantly, 674,592 couples have been protected by contraceptives for one year.

Improving Water Quality, Promoting Hygiene and Sanitation

Poor water and sanitation pose serious public health threats to the Pakistani population, contributing to the spread of diseases and child malnutrition. The mortality rate for children under the age of five in Pakistan is 94 deaths per 1,000 live births. Water- and sanitation-related diseases are responsible for 60 percent of child deaths in Pakistan, with diarrhea estimated to kill 230,000 children under the age of five each year.

USAID's Pakistan Safe Drinking Water and Hygiene Promotion Project is reaching out to 31.7 million people in 40 districts of Pakistan, including six agencies in FATA and eight earthquake-affected districts. This project supports the GoP's Clean Drinking Water for All Project, an ambitious campaign by the GoP to install more than 6,000 water filtration plants, with the aim of ensuring the provision of clean drinking water in every union council. The project work's with people who have access to government-provided water filtration plants to ensure that these plants are properly maintained and become sustainable.

Since most families in the target districts will not have access to water filtration plants in the near future, the project conducts campaigns that improve hygiene and sanitation practices, teach effective household methods of cleaning water and establish health education efforts in schools. To date, trained NGO staff have conducted 268 one-day training workshops for 5,738 teachers (3,612 females) from 5,232 primary schools to carry the message of safe hygienic practices to more than 86,000 families through fourth grade children.

Along with a comprehensive national radio campaign to promote good hygiene and sanitation, these steps will help ensure that this safe drinking water initiative will continue to benefit community members over the long-term.

The project has trained 48 members of communities with water filtration plants and their local government officials in water resources management, maintenance of water filtration plants, water quality testing and the use of simple household water treatment technologies.

Controlling the Spread of Tuberculosis

Pakistan has the eighth-highest incidence of tuberculosis (TB) in the world. According to the World Health Organization (WHO), TB remains one of the leading causes of death due to infectious diseases in Pakistan and is responsible for five percent of the country's total disease burden. An estimated 300,000 Pakistanis contract the disease each year. Thirty percent of the afflicted never get diagnosed, due to limited awareness and abject poverty.

Since 2004, USAID's Strengthening Tuberculosis Control program has contributed nearly $6 million to the National TB Control program in Pakistan. Supporting a WHO community-based program known as DOTS (Directly Observed Treatment Short Course), USAID has provided training to the technical staff who deliver diagnostic services and treatment. USAID also supports district-level managers who supervise and monitor the quality of diagnosis, treatment and reporting at individual facilities.

All government health centers have now adopted the DOTS program. USAID is helping to expand this internationally-approved treatment regimen to the private sector, thus greatly improving identification and treatment throughout the country. Detection of TB cases has tripled since 2003, and the treatment success rate has shown solid improvement.

Building a Foundation for Surveillance and Disease Prevention

Pakistan lacks the epidemiological tools and trained professionals to provide proper disease surveillance - a necessity for health officials to identify, track and treat disease.

USAID's Pakistan Field Epidemiology and Laboratory Training Program (FELTP) is a two-year in-service training initiative developed on the model of the U.S. Centers for Disease Control and Prevention (CDC) Epidemic Intelligence Service.

The program, currently operating in 36 countries around the world, trains epidemiologists to determine disease patterns, conduct infectious disease outbreak investigations and institute control measures under the supervision of an experienced field epidemiologist. The Pakistan program also includes a strong focus on developing laboratory systems to support disease detection.

FELTP has eight students who have completed one year of training. These students will be graduating as field epidemiologists following another year of study. FELTP is in the process of selecting a second group of eleven students. The program has been accredited by the University of Health Sciences in Lahore, Pakistan, and graduates of the program will receive a Master's in Field Epidemiology. FELTP also conducts targeted short courses in the areas of outbreak investigation, surveillance, Avian Influenza, laboratory quality assurance and bio-safety. These courses are typically attended by representatives from the four provinces, federal areas, and national programs.

Eradicating Polio

Pakistan (along with Afghanistan, India and Nigeria) remains one of the only countries in the world with endemic polio. Pakistan has seen tremendous progress in reducing the number of polio cases from 2,635 cases in 1994 to only 32 cases in 2007. The disease has now been geographically restricted with nearly 80 percent of the country's districts considered as polio free for nearly two years.

To build on this success, USAID provides funding to UNICEF through the Pakistan Polio Eradication Initiative to help strengthen routine immunization, hold national immunization days and conduct follow-on campaigns to reach all children who still are unvaccinated. Social mobilization is a particular focus of activities to ensure community demand for immunization. Since multiple doses of polio vaccine are required to achieve full immunity, all children under five must be reached during every campaign.

An ever-increasing number of children have been vaccinated during national immunization days: 29.8 million in 2004; 30 million in 2005; 32 million in 2006; and 33.5 million in 2007. In 2008, (as of 20 May, 2008) Pakistan has conducted two national immunization days. A total of 32.1 million children were immunized during the January campaign. USAID also provides funding to WHO to ensure a reliable polio surveillance system that will improve immunization and disease control efforts that contribute toward the complete eradication of polio.

KEY INDICATORS	2003	2004	2005	2006	2007
Number of Polio cases	99	44	28	39	32
Polio affected districts	43	29	18	13	18

Reducing HIV/AIDS Transmission and Impact

Although Pakistan has a low overall HIV/AIDS infection rate, it has a concentrated epidemic of HIV/AIDS in high-risk groups. Among injection-drug users, infection rates can be as high as 51.5 percent depending on the geographic region. The infection rate among sex workers is four percent. The National AIDS Control Program reports 4,100 people living with HIV/AIDS in Pakistan. However, according to UNAIDS estimates, there are more than 80,000 HIV-positive individuals in the country. Pakistan risks the potential spread of the virus to the broader population if sustained, vigorous action is not taken to contain it.

Expected to benefit more than 122,500 high-risk individuals, USAID's three-year, $3.3 million HIV/AIDS Prevention and Care project promotes awareness about HIV-transmission modes, encourages the ABC (abstinence, be faithful, and use of condoms) approach, and provides voluntary counseling and testing for HIV to approximately 3,700 people.

Since it began in February 2006, the program has reached approximately 41,900 high-risk individuals. It has provided diagnoses and referrals for the treatment of sexually transmitted infections to 3,760 individuals. In addition, the program provides home-based care for 202 HIV-positive individuals and their 608 family members, helping to meet the physical, medical and psychological needs of people living with HIV/AIDS in Pakistan.

Strengthening Health Systems in Pakistan

Pakistan's health systems suffer from an inadequate capacity to provide appropriate training for health practitioners, a lack of accountability to patients and insufficient logistical support for medicines.

In December 2007, USAID began a new project, Strengthening Health Systems in Pakistan. The project will focus on capacity building, disbursing targeted health information, correcting health system deficiencies through small grants and strengthening the logistical systems for essential drugs and contraceptives.

The project's capacity building component, will strengthen institutional faculty, increase sustainability, and improve the performance of services provided by selected organizations whose role in the health sector is critical for low-income and vulnerable populations.

The project will also provide capacity building assistance to two post-graduate nursing and midwifery institutions, the Pakistan Nursing Council (PNC) and the Midwifery Association of Pakistan (MAP). Primary activities will focus on developing a midwifery tutor specialization; strengthening administrative and governing capacity of the PNC and MAP; training midwives, Lady Health Visitors and nurses to improve nursing and midwifery skills; and developing government capacity in health systems development and administration.

Through its targeted health information component, the project will raise public awareness and encourage citizens to hold government administrations and the private sector accountable for providing quality health services. Activities also will include training government officials and journalists in using data for decision making, including results from the PDHS.

The project's grant program will address health systems' challenges in the public, private and commercial sectors, which can be resolved with modest grant assistance within a period of one year. The focus will be on public-private partnerships and innovation in addressing public health problems and health systems issues. A minimum of ten grants of $100,000 each will be awarded.

Through its drugs and contraceptive logistics systems component, the project will strengthen the logistics management information systems of essential medicines and contraceptives in the public sector at the national, provincial and district levels to ensure their availability throughout the country. This activity will work closely with the FALAH program to strengthen logistics at service delivery points below the district level in facilities and with Lady Health Worker supervisors.